Avoidant/Restrictive Food Intake Disorder

When Avoidant/Restrictive Food Intake Disorder Becomes Life Threatening: A Case Report of an Adult Male Patient

Susan L. Bennett, PhD, CEDS; Thomas M. Dunn, PhD; Gillian T. Lashen, PsyD; Jacqueline V. Grant, LCSW; Jennifer L. Gaudiani, MD, CEDS; Philip S. Mehler, MD, FACP, FAED, CEDS*

Introduction texture) of food are believed to mediate willing- 5 Avoidant/Restrictive Food Intake Disorder (ARFID) is ness to eat a non-familiar item. While most of the a recent addition to the fifth edition of the Diagnos- research in this area has been done with children, disgust reactions in adults regarding food has also tic and Statistical Manual of the American Psychiat- 6 ric Association (DSM-5).1 The primary concerns in been established. Presumably, for some individuals, ARFID are that the patient is not consuming enough particular sensory properties of food signal a warn- ing about ingestion, thereby leading to restricted nutrients necessary to meet daily nutritional de- 7 mands and that food restriction is causing impair- eating. Finally, DSM-5 criteria for ARFID note that ment in functioning.2 These concerns are explicitly some people may restrict food intake because of a conditioned negative response, or in anticipation of addressed with one part of the DSM-5 criteria for 1 ARFID: “the persistent failure to meet nutritional an aversive experience while eating. This has been needs resulting in weight loss (or inability to gain explored in the literature and described sometimes choking phagophobia weight in children), malnutrition, reliance on enteral as a , or . Such a fear is typically associated with weight loss and social dys- feeding or dietary supplements, and/or substantial 8,9 dysfunction in everyday functioning.”1 However, un- function. Anticipatory regarding the aver- like (AN), those with ARFID do not sive act of may also result in disordered emetophobia have associated issues with body shape or weight.3 eating. Fear of vomiting, or , has been Instead, there is an associated disturbance in eat- associated with reduced quantity of food eaten (to ing that is attributed to 3 different features that lessen the amount of vomit) and food restriction, comprise the second part of the DSM-5 criteria for either by refusing to eat food prepared by another ARFID: (1) disinterest in eating, (2) aversion to par- person, or becoming highly selective about eating only food items that are perceived as having a low ticular sensory properties of food, or (3) excessive 10,11 anxiety about an aversive event associated with eat- chance of inducing emesis. ing.1 These features will be discussed briefly below. In summary, there are 2 inclusion criteria for ARFID: Disinterest in food or eating is often described as one of the aforementioned 3 eating or feeding dis- selective eating (among other terms) and has been turbances and persistent failure to meet nutritional typically associated with unusually narrow dietary needs. Additionally, there are 3 exclusion criteria to preferences and marked reluctance to try new which the eating or feeding disturbance cannot be types of food, lasting more than 2 years.4 Aversion attributed: it cannot be diagnosed (1) in the setting to sensory properties of food has also been identi- of food scarcity or a culturally-sanctioned practice, fied as a feature of ARFID.1 Perceptions about the (2) during a course of AN or bulimia nervosa (BN), negative sensory properties (particularly taste and nor (3) with a disturbance in how body weight or

*Author Affiliation: Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO (Dr Bennett); ACUTE Center for Eating Disor- ders, Denver Health, Denver, CO (Drs Bennett, Lashen, Gaudiani, and Mehler, and Ms Grant); School of Psychological Sciences, University of Northern Colorado, Greeley, CO (Dr Dunn); Behavioral Health Services, Denver Health, Denver, CO (Dr Dunn); Department of Medicine, University of Colorado School of Medicine, Aurora, CO (Drs Gaudiani and Mehler); and Eating Recovery Center, Denver, CO (Dr Mehler). Drs Bennett and Gaudiani are now with the Gaudiani Clinic, Denver, CO. *Corresponding Author: Susan L. Bennett, PhD, CEDS, Gaudiani Clinic, 4700 Hale Parkway, Suite 380, Denver, CO 80220 (drbennett@gaudianiclinic. com). 18 Bennett, Dunn, Lashen, Grant, Gaudiani, Mehler shape is perceived; moreover the symptoms cannot ports each patient 1:1, and psychiatric consultation as be better explained by a co-occurring medical condi- needed. 1 tion or another mental disorder. Although ARFID Mr X was estimated to be only 68% of his IBW at pre- unites conditions that are associated with restricted sentation and was found to have bradycardia, hypo- food intake (and not associated with other eating tension, leukopenia, anemia, and profound hypotes- disorders), the particular etiology of disturbed eating tosteronism as a result of his severe malnutrition. can be quite varied. Patients who meet criteria for ARFID are a highly heterogeneous group, complicating Mr X first came to medical attention 1 year prior to research and treatment strategies. this admission, when he developed abdominal pain, rectal urgency, and was found to have excessive stool Only codified in the DSM since 2013, research on the and obstipation. He underwent exploratory lapa- 2,12 treatment of ARFID is virtually non-existent. There rotomy with no additional findings. The symptoms is also a paucity of research regarding those with resolved following extensive chemical and mechanical ARFID who are severely medically compromised. In bowel disimpaction. A recurrence of symptoms fol- this article, we present such a case—a young adult lowed some months later, and Mr X was admitted to male with severe malnutrition secondary to food a hospital with severe obstipation and fecal vomiting. restriction not related to fear of weight gain. Our aim He was subsequently diagnosed with Celiac , is to provide guidance for diagnostic assessment and confirmed by both biopsy on upper endoscopy and psychotherapeutic intervention for medically unstable antibody testing. Celiac disease is prevalent in his patients with ARFID. family. He reported seeking treatment due to a 30-pound Case Report weight loss over the past year. This weight loss was In February of 2015, a markedly emaciated 18-year- attributed to the patient restricting intake and follow- old male, Mr X, presented to the ACUTE Center for ing a strict gluten-free diet, as well as avoiding red Eating Disorders (ACUTE) at Denver Health Medical meat, dairy products, and processed foods due to fear Center for treatment of severe malnutrition. ACUTE is of abdominal pain. Mr X also denied eating junk food. a 15-bed medical stabilization unit for medically com- Additionally, he frequently played soccer and went promised adults with eating disorders who require snowboarding. medical stabilization prior to transfer to traditional With his family’s support, he agreed to enter an eat- mental-health focused inpatient or residential eating ing disorder program. However, out of concern for his disorder programs across the United States. Indica- degree of medical instability, the program referred tions for admission typically include patients with an- him initially to ACUTE to begin weight restoration and orexia nervosa restricting subtype (AN-R) whose body medical stabilization. weight is less than 70% of ideal body weight (IBW); patients with anorexia nervosa binge-purge subtype Physical Findings (AN-BP) whose body weight is less than 75% of IBW but who have concomitant severe electrolyte abnor- Presenting weight, IBW, body mass index (BMI), vital malities or prior inability to cease purging behaviors signs, noteworthy laboratory studies, and electrocar- because of severe edema formation; patients with diogram interpretation are given in Table 1. ARFID who meet weight/medical complexity criteria Diagnostic Assessment as described above; and patients with a serious and another concurrent medical diagnosis Following an initial diagnostic interview and as- which makes stabilization in a specialized medical set- sessment, Mr X agreed he was and ting preferable and safer. The ACUTE team follows a understood the seriousness of his malnutrition. He multidisciplinary approach to patient care. The clinical explained that his restrictive diet was in service of team includes an attending internal medicine physi- avoiding abdominal pain and/or constipation, as well cian, clinical psychologist, registered dietitian, social as optimizing his athletic performance. He did not worker, physical therapist, occupational therapist, present as being preoccupied with his appearance or registered nurse, certified nursing assistant who sup- driven for thinness. No fear of gaining weight was not-

19 Avoidant/Restrictive Food Intake Disorder

ed. He denied symptoms associated with depression, hospitalization. Mr X had a close relationship with his anxiety or other psychiatric disturbance, and there family, and he was encouraged to utilize those rela- was no history of substance use disorder. tionships for support. Eating disorder type was determined collaboratively During Mr X’s hospitalization, standard ACUTE medical between the clinical psychologist and attending physi- protocols were employed, included 24-hour telem- cian, based on the patient’s clinical presentation and etry, labs, blood glucose checks every 4 hours, warm- the DSM-5 inclusion and exclusion criteria. Mr X met ing blanket, an individualized meal plan beginning at the diagnostic criteria for ARFID. 1800 calories and increasing by 400 calories every 3 days, and 24-hour 1:1 support from a certified nursing Therapeutic and Medical Interventions assistant. Primary aims of psychotherapy with Mr X included Near the end of his hospitalization, emphasis was psychoeducation, stress management, and motiva- placed on preparation for discharge and ongoing care. tion for recovery. There have been studies finding On hospital day 15, Mr X was determined to be medi- cognitive impairment in individuals with malnutri- cally stable based on a varied and well-tolerated meal tion before treatment followed by improvements in plan of 3800 calories daily, 3.9 kg weight gain, normal cognitive functioning following weight restoration.13-16 laboratory values and vital signs, acceptable bowel Accordingly, insight and cognitive-oriented therapies function, and physical strength sufficient to support were deemed unlikely to be effective for Mr X in his his participation at a lower level of care. While Mr X malnourished state. Instead supportive psychother- lacked body image concerns and traditional eating apy was utilized to reinforce his ability to cope with disorder behaviors, he did require additional support the stress associated with hospitalization while also and education in the reintegration of dietary variety, cultivating resilience and hope. Daily therapy sessions nutritional soundness, adaptive coping skills, and fur- were conducted at his bedside 6 days a week and ther weight restoration. He was therefore discharged were approximately 30 minutes in length to accom- to an eating disorder-focused partial hospitalization modate for his diminished cognitive endurance. Ac- program. tive listening encouraged him to express thoughts and feelings to gain a broader understanding of his situa- Discussion tion and options. Therapeutic assignments, journal- ex ercises, and various games were employed. As Mr X’s This case was unique given that Mr X was a severely cognitive capacity improved with weight restoration malnourished young adult male requiring medical and medical stability, Acceptance and Commitment intervention. He sought treatment only after he lost a Therapy (ACT) was introduced. ACT is an empirically- considerable amount of weight and became medically based behavioral and cognitive therapy that focuses compromised. Mr X demonstrated disordered eating. on mindfulness, acceptance, cognitive defusion, and He was malnourished due to restricting caloric intake. values.17 Mr X identified top values of family, school, However, he did not demonstrate an intense fear of athletics, and interpersonal relationships. In therapy gaining weight or undue influence of body weight or sessions he learned to reframe the difficult work of shape on his self-evaluation. As such, Mr X did not recovery as committed action towards his values. He meet criteria for AN-R; rather, his concern about the was eager to return to his senior year of high school aversive consequences of eating combined with no- and found the relative inactivity of his hospitalization table weight loss and significant nutritional deficiency challenging. In response, Mr X’s sessions also focused exemplified the diagnostic criteria for ARFID. It is not on helping him to tolerate his medically-indicated uncommon for ARFID patients to seek treatment only decreased activity levels and the length of his hospi- when they come to the attention of medical profes- tal stay. Additionally, stress management skills were sionals following significant weight loss as they do not taught; while Mr X did not demonstrate difficulty with have the body image preoccupation present in AN; meals nor was he anxious about food, he did occa- therefore, dietary behaviors often go unnoticed. sionally struggle with the challenges associated with Mr X responded positively to psychotherapies typi- first-time eating disorder treatment and refeeding cally used during a medical inpatient hospitalization

20 Bennett, Dunn, Lashen, Grant, Gaudiani, Mehler for AN, specifically supportive psychotherapy and Follow-Up ACT. Certainly, psychotherapy has been effective in 18 Ten months after he completed treatment, Mr X the treatment of other eating disorders. However, reports doing “very well.” He feels “great” physically severely medically-compromised patients with eating and emotionally and has had no recurrence of bowel disorders may be unable to engage in cognitive be- or digestive issues. He completed his senior year of havioral therapy due to the cognitive impairment as- 19 high school and is now attending college in engineer- sociated with starvation. Supportive psychotherapy ing. He remains active in his athletic pursuits and has even at a medically-compromised stage of illness has 20 a circle of friends. Importantly, Mr X is maintaining a shown promise. In a randomized controlled study weight of 67.3 kg (107% IBW, BMI 23.2 kg/m2). Ad- comparing cognitive behavioral therapy, interpersonal ditionally, he is eating a wide variety of gluten-free therapy, and supportive psychotherapy (nonspecific foods. His family reports he is “doing really well.” supportive clinical management) for AN,21 more participants improved with supportive psychotherapy (58%) than with cognitive-behavioral therapy (32%) Conclusion or interpersonal therapy (10%).21 Supportive psycho- This case report contributes to the literature by de- therapy appears best suited for people who are trying scribing the treatment of an adult male with a severe, to cope with an acute medical situation.20 life-threatening presentation of ARFID and its atten- Psychotherapy for severely-ill ARFID patients varies dant medical compromise. Although the diagnosis from traditional treatment for AN or BN. While pa- was previously described as a disorder of childhood, tients with ARFID share many of the same medical the DSM-5 recognizes that ARFID occurs across the concerns, psychological processes differ in important lifespan. With the expansion of this diagnosis there ways. Specifically, ARFID patients do not experience are increased opportunities for clinicians to identify distress associated with distorted body image, nega- patient behaviors that have the potential for serious tive assessment, or fear of weight gain. Therefore, it health consequences. Additional case reports and is critical to adapt psychotherapy to exclude interven- empirical studies regarding treatment of ARFID are tions addressing body image and weight-related con- needed to guide medical and mental health profes- cerns. Failure to recognize this difference may alienate sionals in the management and treatment of this patients in treatment and decrease efficacy of thera- disorder. Providers should be aware of the diagnosis peutic interventions. Patients are generally able to use in order to make appropriate referrals to specialized interventions aimed at decreasing anxiety and help- programs, where patients can safely restore weight, ing them to cope with hospitalization and the rigor of learn new skills, and begin making life-saving changes medical stabilization. In this case, coping skills were in their approach to meeting nutritional needs. taught to help the patient manage stress to make the hospitalization more tolerable. As this patient pro- gressed in his nutritional rehabilitation and medical stabilization, ACT, a cognitive behavioral-based thera- py, was introduced to advance treatment.22 Observing and accepting thoughts while taking action based on values (major tenets of ACT) help especially rumina- tive, perseverative patients advance in treatment and recover cognitively. These interventions also prepare the patient for the next level of care in a behaviorally- based program, which focuses on behavioral change while achieving final weight restoration.

21 Avoidant/Restrictive Food Intake Disorder

Tables Table 1. Mr X’s presenting weight, BMI, laboratory data, vital signs, and ECG interpretation Type of Data Data Weight 43.4 kg Ideal Body Weight 68% Body Mass Index 15.2 kg/m2 Laboratory Values (normal range) Sodium (135–143 mmol/L) 139 Potassium (3.6–5.1 mmol/L) 4.4 Chloride (99–110 mmol/L) 103 Bicarbonate 30 Glucose (60–199 mg/dL) 73 Blood urea nitrogen (9–21mg/dL) 12 Creatinine (0.50–1.39 mg/dL) 0.6 Calcium (8.1–10.5 mg/dL) 8.9 Magnesium (1.3–2.1 mEq/L) 1.6 Phosphate (3.1–5.0 mEq/L) 3.4 Alkaline phosphatase (78–577 U/L) 49 Albumin (3.0–5.3 g/dL) 4.2 Aspartate aminotransferase (10-40 U/L) 27 Alanine aminotransferase (20–60 U/L) 70 Testosterone (300–1080 ng/dL) 46.1 White blood cell count (3.5–10.5 mL) 3.4 Hemoglobin (13.5–17.5 g/dL) 12.2 Hematocrit (38.8–500%) 35.9 Platelets (150–450 K/uL) 127 Other Hematology Values Absolute neutrophil count (1.5–8.0%) 1.7 Erythrocyte sedimentation rate (0–22 mm/hr) 1 Vital Signs Supine Standing Heart rate 51 42 Blood pressure 108/71 94/59 Respiratory rate 18 16 Temperature 35.6 Electrocardiogram Sinus bradycardia (HR=36) Corrected QT interval 378 ms Abnormal ECG

22 Bennett, Dunn, Lashen, Grant, Gaudiani, Mehler

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